Memorandum by Dr Liam O'Hara (PS 47)
With respect to your call for opinions on your
inquiry into Patient safety, I wish to submit some views from
the perspective of a medical practitioner in primary care with
a Healthcare law degree.
1. To begin with I think one ought to restate
elements of the Hippocratic Oath, which provide insights into
"|I will prescribe regimen for the good
of my patients according to my ability and my judgement and never
do harm to anyone. To please no one will I prescribe a deadly
drug, nor give advice which may cause his death|"
"|If I keep this oath faithfully, may I
enjoy my life and practise my art, respected by all men and in
all times; but if I swerve from it or violate it, may the reverse
be my lot."
Allied to these touchstones one must add the
pillars of aspiration and professionalism to understand the positive
virtues of "the medical personality". How these virtues
are nurtured in the case of the NHS by utilitarian and political
envelopes seems to be the nub of your inquiry.
2. Patient safety is core to medical practice
in the sense of "duty of care", it can become diluted
and disfigured when utilitarian agendas manifest. The hand holding
the smoking gun describes the individual element of the
error, and is an easy target to attach blame, and whichever flavour
of accountability to circumscribe the individual's contribution.
Systemic accountabilities have traditionally been very difficult
to ascribe a legal personality to and hitherto, especially in
the case of the NHS, have slid away from any judicial examination.
It is a common given that the greater bulk of responsibility for
clinical negligence ie derogated patient safety, is to be found
in system failures.
3. Clinical practice is not a science but
an art, it employs science to direct and instruct the art, within
the therapeutic relationship. Indeed clinical practitioners are
a sump to absorb and manage the risk brought forth in the
therapeutic encounter. Directed initially by non-malificence they
already utilize the precautionary principle, prior to any beneficent
act they may be able to offer. Thus far practitioners have been
judged in the civil setting according to a justifiable and reasonable
standard. This reasonable ingredient within a standard
of adjudication allows for manipulation; it is not an aspirational
standard. Plainly avoidable risk has to be defined to a standard,
one described to the expert standard of conduct rather than the
reasonable standard, fulfils the aspirational quest, and extinguishes
manipulation of the reasonable standard.
4. I do not think there is any public perception
of the interplay between risk and health policy, political manipulation
has packaged healthcare into a commodity containing a warranty.
This mixture of a service product containing risk
defines our current attitude to patient safety. Can clinical practice
ever be risk-free? Plainly the answer is no, can risk be understood
and contained or reduced? I think the answer to this is yes.
5. How then to understand clinical risk
and its management? Secondary care contains clinical risk managers,
who educate clinical staff as to risk and examine complaints.
In primary care a far looser risk management/analysis exists,
beit at a micro (practice level), local (geographic level) or
Primary Care Trust (PCT) level. Beyond these levels we have NPSA,
NHSLA, Healthcare Commission, Ombudsman and perhaps even the Coroner.
Indeed a formidable tapestry. The key to risk and its understanding
is communication. To what degree, if at all, do the threads listed,
communicate between each other, and if so, what and to whom do
they educate? Experience is that the National Health Service titleage
is a misnomer, pit face experience directs a different
eponym FHS, namely Fragmented Health Service. In the instant inquiry
pertaining to patient safety it is the experience of practicing
clinicians which is paramount as to their perception how risk
is managed at a personal, practice, departmental level and how
the agencies listed above interact with pit face personnel.
Education is a two way process, 24/7 and the FHS could learn from
creative external bodies such as Toyota with its Zen constructs
of genchi genbutsu - go and see for yourself, kaizencontinuous
improvement, jikote kanketsu - quality through ownership,
jishoken - fresh eyes approach, and yokoten - sharing
and cascading lessons learnt. This example provides the tools
for innovative assimilation of risk events. To see a system
currently working and adopting the ingredients of this committee's
inquiry one has to look at the Scandinavian No-Blame compensation
system as exemplified by "Patientfðöñrsðäñkringsfðöñreningen",
this system has been working since the early 1970's. Originating
initially in Sweden, over the last five years, all its Nordic
neighbours have now embraced the system.
6. The terms of reference in this inquiry
use terms such as "adequate measurement", "policy",
"appropriateness of the objectives", "national
policy", "cost effective", and "national targets".
This slavish pursuit of objective measurement, the easily measured,
neglecting the more important virtue of what is not measurable
is usually more important (Gresham's law). Indeed ".. what
gets measured gets managedeven when it's pointless to measure
and manage it, and even if it harms the purpose of the organisation
to do so..." The purpose of any exercise involving managing
human conduct/behaviour needs sage counsel lest it fall into the
law of dysfunctional consequences. Mintzberg a management educator
proposed that starting ".. from the premise that we can't
measure what matters gives managers the best chance of realistically
facing up to their challenge". It is too easy to fall into
the example of "|Corporate managers start off trying to manage
what they want, and finish up wanting what they can measure|"
Plainly measurements if valid and valuable need to be formulated
in knowledge of the above observations.
7. From the perspective of current effectiveness
of NPSA, NHSLA, and the Healthcare commission upon clinician's
behaviour at the pit face, I think the majority of practitioners
are aware of the alphabetical contribution to the titles, but
little more. This says it all; one cannot communicate across a
vacuum. Communication and dialogue are everything.
8. Targets and the naive simplicity they
derive from are delusional; Ackoff has distilled it as "..
the only problems that have simple solutions are simple problems.
The only managers with simple problems are those with simple minds.
Problems that arise in organisations are almost always the product
of interactions of parts, never the action of a simple part".
Focussing on top down mantra and targeting the individual parts
in a shame/blame guise makes things at a system-wide level function
worse. If enough pressure is applied people will meet targets,
and in doing so destroy the organisation. So called junk management
without any sentience of genchi getsubu leads to discontent,
demoralisation and dysfunctional behaviours. The absence of any
method and the deification of the target lead to disengagement.
9. What is needed is acknowledgement of
something akin to genchi getsubu and a system that cultivates
and co-ordinates risk analysis in an aspirational environment
with none of the traditional shame/blame destructive schemas.
Such a model exists within the Toyota Production System, as alluded
to earlier. The cards already exist in the poker game that is
healthcare; the problem is, the hand that is playing them. The
agents and organisations need a truly independent compass, allied
to this they need to be trusted without any application of political
shackles. As is plain in the human condition handbags and super-egos
can disrupt the best laid plans; collegiate and statutory bodies
are not immune from such agents.
10. Patient safety is a 24/7 construct with
hot spots appearing at certain times of the day, days of
the week and seasons of the year. It is something that needs cognisance
of its cycles and the human and systematic contributions.
What is needed is a more sage use of the boards and agents that
already exist; an independent Board of safety separate from all
other boards would be a start. This body would be allowed to shape
the garnering of pit face experience and facilitate its
experience to feed into the executive and be allowed to direct
policy with patient safety as its remit. This plainly will feel
alien to management if not apocalyptic. However this is their
problem and indeed I would say the current situation is of their
creation beit through higher coercion. The solution involves innovative,
creative let us say it, "World Class thinking". In a
public service aping "World Class provision", patient
safety is plainly a tandem passenger on this journey.
11. World Class direction of clinical care
and patient safety involves putting the professionals back in
the driving seat without any utilitarian obfuscation as to dilute
the recipe. The ingredients of any Board of safety would be risk
managers, clinicians, hospital legal representatives, operational
directors, and an executive champion. It would have a 24/7 presence,
with active communication and dialogue with all healthcare delivery
personnel. The chair of the board needs to be a rather special
chef, someone who is an experienced clinician and one mindful
of Root cause analysis, accountability, legal issues, transparency,
allied external bodies above all approachable, a sense of humour
and with no axes, apart from patient safety, to grind. A tall
order for an alchemist! I have recently seen a novel structure
made manifest, the NHS Institute is making attempts to cultivate
medical leadership at undergraduate and junior level, which could
be harmonized into risk management educational role.
12. Primary care, how does risk management
sit in this field? I would say in a piece-meal manner. The same
TPS system approach I have described for secondary care could
be levied at primary care with all its agents. The co-ordination
of the information received is perhaps the most difficult, and
could be the most beneficial. I would suggest the Coroner service
be given a pivotal role in the assimilation and co-ordination
of patient safety issues by all primary care staff, they feeding
information to the coroner by a card service similar to the Yellow
card system used for suspected adverse drug reactions. The
Coroner being independent from PCT's and any political manipulation
would facilitate an aspirational democracy for patient
safety in the largest pool of NHS to patient contact (90% of patient
contact with the NHS is through primary care). The Coroner being
a medical and legally minded agent has the necessary remit and
skills to hold this candle. This pivotal agent could then utilize
the knowledge gained in dialogue with the board of safety in secondary
care to inspire a virtuous cycle of continuing improvement in
patient safety, an important side effect of this being improved
healthcare provision. Dialogue between the Ombudsman, or an amalgamation
of this role into a locality driven patient safety division, driven
by lessons learnt from complaints (Kaizen) would provide
a new way of using complaints and clinical experiences to improve
the patient experience and amplify patient safety in Healthcare
13. In my estimation "cost-effective"
is an anathema to patient safety, and ought to be removed from
usage in this instance.
14. The implementation of learning from
clinical risk pulls the discourse towards the composition of using
the utility garnered to deter future occurrences; allegedly one
of the basic elements of Tort law, but one rarely seen
in the quest for Quantum. The Quantum of education
is one impossible to numerate, but is plainly far more valuable.
Members of the Medical indemnifier organisations receive missives
about cock-ups, and the respective practitioner contributions
within, allied to advice upon how to avoid repeat; so too ought
the NHS. Education and dialogue stimulate confidence in systems
and people; this creates positivism inspiring the individual and
the system to aspire to yet higher achievement. Education can
be oral or written, I see education as being a fundamental vista
upon the employer, indeed a duty. The spectacular failure of the
NHS University demonstrates the fact it is not the body but rather
people that make things happen. Local education like cellular
networks provide the best coverage of populations, the value placed
upon the agents of education shows how much the system values
the message. Such agents need the capacity and personality to
engage the topic, one that is not easy but is core to all healthcare
providers. Indeed an old observation is that ".. risk is
everyone's business..", none more so than in the context
of Healthcare. Imaginative solutions need to be harvested and
grasped lest this slip from the conscious mind.
15. Summarising I feel Healthcare is a game
of cards, whichever game you want to play it is the manner in
which the respective cards are played as to the rules of the game.
Axiomatic to the delivery of Healthcare is the analysis of risk,
something that practitioners do on a daily basis. Trying to elevate
the functioning of healthcare delivery plainly feeds into practitioner
philosophy and morale. Utilizing subtle psychological schemas
to feed into the practitioner psyche requires innovative ideas
which policy makers need to be aware of. Central to all human
endeavour is trust, without this fundamental ingredient all fails.
Avoidability is a given necessity in my view to address patient
safety and the practitioner component borne within, addressing
this sagely ought to reinvigorate professionalism. Utilizing aspects
of the Toyota Production System and looking towards a Scandinavian
No Blame model of compensation would provide a start to advancing
this agenda. Profitable shuffling of the current agents within
the game such as the Coroners office, Board of Safety and emulating
the Yellow card schemes would strengthen the tapestry of
patient safety. Above all education of all healthcare providers
on a continual non-threatening basis is the route to strive for,
placing the therapeutic relationship at the heart of any lessons
to be learnt, apologies to be made and wisdom to be imparted.
Any healthcare system revolves around people, by this I mean the
patient and practitioner. Central to it will always be the style
and manner of the therapeutic relationship. Employing the abstract
of avoidability to an expert standard is something all practitioners
at an individual level strive for, and is something we ought systematically
nurture and protect. The manner of its cultivation and shepherding
is something that needs great care, caution and sensitivity. Its
success would be central to a "World Class" Health Service.
I am indebted to Simon Calder and his management
column in the business section from "The Observer" for
his alternative view point on "management".
I have found the tome "Errors, Medicine
and the Law" by Alexander McCall-Smith and Alan Merrey a
valuable seam of wise observations.
I am indebted to all on "Doctor Net UK"
for their eclectic mixture of wit, observation, experience and
reality that helps to give this website its sage personality,
and informs all who visit it.
"Clinical Risk Management" by Charles
Vincent et al.
"Structural change in healthcare: what's
the attraction?" Coid & Davies, JRSM Vol 1001, No 6,
Dr L.M. O'Hara, MB ChB